Welcome to MHPN’s first GP focused webinar on collaborative care for people with chronic pain and mental health issues. We will begin at 7:15pm AEDT.
Webinar An interdisciplinary panel discussion Collaborative care for people with chronic pain DATE: November 12, 2008 and mental health issues; an interdisciplinary case study panel discussion for general practitioners . Wednesday 21 st November 2012 Supported by The Royal Australian College of General Practitioners, the Australian Psychological Society, the Australian College of Mental Health Nurses and The Royal Australian and New Zealand College of Psychiatrists
This webinar is presented by Panel o Dr Stephen Leow (GP) o Mr Nick Economos (physiotherapist) o Dr Jacqui Stanford (psychologist) o Dr Tobie Sacks (pain psychiatrist) Facilitator o Dr Mary Emeleus (GP)
Learning Objectives This webinar will: • Help improve your understanding of the relationship between chronic pain and mental health • Improve your referral pathways, by identifying the role of different disciplines in contributing to the assessment, treatment and management of people with chronic pain and mental health issues • Explore GP specific tips and strategies for interdisciplinary collaboration in supporting people with chronic pain and mental health issues.
What are we taught about pain? • Pain is the result of disease or injury • Pain is proportional to the damage from disease or injury • If we cure the disease or fix the injury, the pain will go away • If the pain doesn’t go away, it is in the patient’s head • There is something called neuropathic pain, which comes from nerve damage Dr Stephen Leow (General Practitioner)
IASP Definition of Pain “An unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage.” Dr Stephen Leow (General Practitioner)
What we would like you to consider… • Pain does not simply equal injury and vice versa • Pain is complex and many things affect our experience of pain • We can do much to influence outcomes, simply by being aware of these factors • Chronic Pain is very much a general practice issue Dr Stephen Leow (General Practitioner)
We really can have an impact on pain! • Psychological factors have a major impact on our perception of pain • What we say, do and act has an impact on pain • We are often unaware of the way of how pain unfolds • Small shifts in what we do can have major impacts on outcomes! Dr Stephen Leow (General Practitioner)
Physiotherapist perspective Assessment: o Current treatment is passive which is not evidence based for the management of chronic pain o Knee and back pain continue despite scans clearing sinister pathology o High Orebro score signifies that addressing psychosocial factors in a co-ordinated approach is necessary o Current physiotherapy treatment may be providing supportive "counselling" and social contact Mr Nick Economos o Early psych referral to address psycho-social (physiotherapist) factors
Physiotherapist perspective Management: o Education that pain may not relate to further harm but it is real o Early shift from passive to active approach required o Set goals and communicate o Importance of increasing function/re- engage in meaningful activity to reduce pain Mr Nick Economos (physiotherapist)
Physiotherapist perspective Management: o Provide graded exposure to movement through exercise and through gradual upgrades in activity (cooking/walking/dancing/work/household chores) o Utilise the benefits of returning to work o Communicate with other treaters and employer/insurer o Develop self management strategies Mr Nick Economos (physiotherapist)
Psychologist perspective Role of Psychology: • Psychosocial factors – Including conflict, fear, worry, stress, coping – Often a small number of sessions • Mental Illness – Pre-existing – Secondary to an injury Dr Jacqui Stanford (psychologist)
Psychologist perspective What to look for in an assessment: • Standard psychosocial assessment – Including mood and sleep • Pain and Function Assessment – Factors at the time of injury that may have precipitated the presentation – Understanding and beliefs about pain – Impact on function Dr Jacqui Stanford – Acceptance (psychologist)
Psychologist perspective Goals and Treatment Plan: • Functional goals are very important, not simply focusing on symptom reduction • The goals are the clients and therefore ideally all treaters know the goals and can look at how their intervention can facilitate achievement • The treatment plan should focus on addressing the barriers to achieving the Dr Jacqui Stanford (psychologist) goals
Psychologist perspective Treatment: • Biopsychosocial approach – need to consider the whole person • Function needs to be a part of treatment, not something that happens at conclusion • RTW is all treater’s responsibility, important to find psychologists with understanding of this area • Communication with other stakeholders/ treaters is needed Dr Jacqui Stanford • Cognitive Behaviour Therapy and Acceptance (psychologist) and Commitment Therapy
Psychiatrist perspective Bron has decompensated: • Unable to cope with the persistent, intractable pain and its consequences, she has become depressed, i.e. she has, in addition to the chronic pain disorder, developed an adjustment disorder with anxiety & depressed mood. Dr Tobie Sacks (pain psychiatrist)
Psychiatrist perspective Bron’s failure to adjust to the chronic pain is the result of her: a) Lack of understanding about the nature of her pain (she believes that the persistent pain reflects continuing damage) b) Lack of any effective strategies to deal with her pain when it arises or flares up (other than passive ones that result in escalating dependence on either drugs or other people) resulting in kinesiophobia, reduced self- efficacy, reduced self-esteem, and demoralization c) Lack of any strategies or avenues to grieve for or to deal Dr Tobie Sacks with her losses – financial, personal and emotional – (pain psychiatrist) resulting in feelings of helplessness, hopelessness and despair
Psychiatrist perspective If Bron were referred to me I would be focusing on: a) Reducing her emotional distress by • providing her with information about the underlying pathology (central sensitization of her pain pathways) • facilitating her gaining understanding of the relationship between her pain (the sensation), her emotions (how the pain makes her think and feel) and her behaviours (how the pain affects her gait, posture and other behaviours) • Dr Tobie Sacks I might also introduce an antidepressant (pain psychiatrist) drug.
Psychiatrist perspective If Bron were referred to me I would be focusing on: b) Reconditioning her responses to pain by: • providing self-management strategies to control her pain • reducing her reliance on medications and passive treatments • changing social and environmental contingencies that enhance sick-role behaviours (e.g. Bill taking over all of her former domestic activities) Dr Tobie Sacks (pain psychiatrist)
Psychiatrist perspective If Bron were referred to me I would be focusing on: c) Facilitating her re-engagement in normal meaningful activities by: • encouraging her to become an active participant in her own recovery • engaging in moderate exercise • reinstating some of her former Dr Tobie Sacks social and other meaningful (pain psychiatrist) activities.
Psychiatrist perspective Key Messages: 1. Anxiety and depression are very common in patients suffering from chronic pain. 2. Chronic pain both aggravates and is aggravated by anxiety and depression. 3. Treatment of patients with chronic pain disorders needs to address not only the management of the pain itself but also the emotions and behaviours that result (a) from the changes in the patient’s circumstances and (b) their mistaken/erroneous beliefs (and expectations) about their pain Physical treatment alone – fails Passive treatment alone – fails Dr Tobie Sacks Psychotherapy alone - fails (pain psychiatrist)
GP perspective History: Descartes View of Pain Dr Stephen Leow (General Practitioner)
GP perspective Pain History • Location • Nature • Dull • Sharp • Aching • Burning… • Intensity • Radiation • Exacerbating or Relieving Factors Dr Stephen Leow (General Practitioner)
GP perspective Examination: The RED Flags • Infection • Fracture • Malignancy • Nerve Compromise Dr Stephen Leow (General Practitioner)
GP perspective Investigations: for Back Pain • X-ray • CT Scan • MRI Scan • Bone Scan • Nerve Conduction Studies • DEXA Scan • Bloods (for signs of infection) Dr Stephen Leow (General Practitioner)
GP perspective Treatment: Options • Analgesia • Simple i.e. Paracetamol, NSAIDS • Rest • How long? • Language • Physiotherapy • Review Dr Stephen Leow (General Practitioner)
GP perspective Review: non progression • Red Flags? • Need investigation now? »What? • Yellow Flags? Dr Stephen Leow (General Practitioner)
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